An Unusual Presentation of Midline Lethal Granuloma

Extranodal natural killer T-cell lymphoma, nasal type (ENKTCL), is a rare form of non-Hodgkin lymphoma that is strongly related to Epstein-Barr Virus (EBV) infection and commonly presents as "midline lethal granuloma." Herein, we report a middle-aged lady who presented with a two-week history of fever, sore throat and constitutional symptoms. Intraoral examination revealed a lacerated soft palate with an ulcerated uvula. A diagnosis of ENKTCL was confirmed through deep biopsies under general anaesthesia supplemented with a positive serum EBV genome. Unfortunately, she succumbed due to disease progression with left frontal brain metastasis with concurrent pulmonary tuberculosis before treatment was completed. The recommended treatment is multimodality with L-asparaginase-containing regimes chemotherapy in an advanced stage, relapsed, or refractory ENKTCL for better outcomes. The quantification of circulating plasma EBV deoxyribonucleic acid (DNA) is helpful as the baseline of tumour load and a biomarker for monitoring treatment response and prognostication. We advocate repeated and deeper core tissue biopsies.

Familial congenital laryngotracheal stenosis: A systematic review

BACKGROUND

Congenital laryngotracheal stenosis (CLS) is a rare cause of stridor among newborns. Evidence has shown that several family members can be affected by CLS. Knowledge of the pathophysiology of familial congenital laryngotracheal stenosis (FCLS) will enable more effective therapeutic strategies.

OBJECTIVE

To determine the clinical course and outcome of familial congenital laryngotracheal stenosis (FCLS).

METHODS

A literature search was conducted over a period of one month (September 2023) by searching several databases to identify studies published from inception to 31st August 2023.

RESULTS

Of 256 papers identified, five articles met the inclusion criteria. A total of 17 patients with slight female predominance (59 %) were identified. Familial congenital tracheal stenosis was reported in female twins (100 %). A variety of clinical presentations were listed. An endoscopic airway study was performed on all patients. 64.8 % of the included children were managed surgically. Genetic studies performed on 41 % of children could not locate genetic abnormalities.

CONCLUSION

Consanguinity, twin births, and female gender could be predisposing factors for FCLS, although the quality of evidence is low due to the rarity of the condition.

Role of Video Head Impulse Test to Assess Noise Exposure

Noise exposure has been reported to exert numerous detrimental effects on the human population, although most research has centred around hearing damage. Vestibular and balance loss have been demonstrated among industrial workers, although reports on this are still scarce. Vestibular loss increases the risk of falls, especially among industrial workers who are at constant risk. Nonetheless, the ideal investigation tool to investigate vestibular function remains unknown. We aim to review the available literature to elucidate the effect of noise exposure on semicircular canals using a video head impulse test (vHIT). A literature search identified only three studies involving 137 patients (mean age: 44.4). Semicircular canal deficit was found in 50.4% of the included participants, with lateral canal predominantly affected (71%). We highlight the importance of assessing the effect of noise exposure on vestibular function, especially among those prone to occupation-related vestibular loss.

Cervical bronchogenic cyst in a toddler

Bronchogenic cyst is a congenital abnormality arising from the tracheobronchial system. Localisation of such cysts in the head and neck region is rare. We report a girl in her early childhood with a painless enlarging right lateral neck mass diagnosed with a branchial cleft cyst based on clinical and radiological MRI findings. An incidental finding of a cervical bronchogenic cyst was made on the final histopathological specimen. Although rare, bronchogenic cysts should be considered as differential diagnoses for paediatric patients' lateral and midline cervical masses.

Acute labyrinthitis: a manifestation of COVID-19 in a teenager

Audiovestibular symptoms following COVID-19 have been long acknowledged, especially in adults. However, acute labyrinthitis presenting as an early manifestation of COVID-19 has not been reported in children. We report COVID-19-induced acute labyrinthitis in a teenager. We report on a boy in his early adolescence with a sudden onset of spinning sensation, imbalance and unilateral hearing loss with a positive SARS-CoV-2 test. Vestibular investigations point towards right labyrinthine hypofunction, and an audiometry test revealed right-sided severe hearing loss. Symptoms improved gradually with steroids and vestibular rehabilitation therapy. However, the long-term repercussions of post-COVID-19 acute labyrinthitis are unknown and must be followed up closely. To our knowledge, this is the first reported case of acute labyrinthitis secondary to COVID-19 in paediatrics. Additionally, we conducted a literature search to elucidate the outcome of COVID-19-induced acute vestibular syndrome in children.

Could Cultural and Background Resilience be the Main Culprit for Neglected Vestibular Dysfunction in Children?

Vestibular dysfunction in children and adolescents has recently gained tremendous attention, with more child-friendly investigations and rehabilitation protocols emerging.Reports have shown that children with vestibular impairment tend to develop speech and language acquisition delay, fine and gross motor delay, which in the long-termresults in an overall poor quality of life. In an extreme situation, vestibular dysfunction can lead to dissociative syndromes such as depersonalisation/derealisation symptomsthat occur following a mismatch between the vestibular signals and other sensory inputs, which may, in turn, lead to suicidal thoughts and behaviour 1. Whilst measuresto incorporate vestibular assessment as a part of routine practice in paediatric patients have been carried out in most centres, pediatric vestibular medicine appears to beunfathomed in some parts of the world, notably the South-East Asian region.

High-Riding Inominate Artery: Challenge During Tracheostomy

An aberrant vessel presenting as a pulsatile neck mass poses a significant challenge intraoperatively if overlooked during the pre-operative period. We present a case of a high-riding innominate artery (HRIA) just above the suprasternal notch, with the right common carotid artery crossing the midline just inferior to the thyroid gland in a 72-year-old lady referred for tracheostomy. The surgeon operating on the anterior part of the neck must be aware of the HRIA and equipped with sufficient knowledge of interventions that may be adapted to prevent injury. We aim to highlight the importance of careful investigations of subtle signs which may lead to the diagnosis and treatment with a review of various interventions for this unusual condition.

X-Linked Gusher Disease DFNX2 in Children, a Rare Inner Ear Dysplasia with Mixed Hearing and Vestibular Loss

Conductive hearing losses are typically present in disorders of the external/middle ear. However, there is a rare group of inner ear conditions called third windows that can also generate a conductive hearing loss. This is due to an abnormal connection between the middle and the inner ear or between the inner ear and the cranial cavity. X-linked gusher disorder is an extremely rare congenital inner ear dysplastic syndrome with an abnormal connection due to a characteristic incomplete cochlear partition type III and an incomplete internal auditory meatus fundus. The disorder is inherited in an X-linked fashion due to the mutation of the POU3F4 gene. We present two siblings diagnosed with the condition and their long-term follow-ups. They both presented audiovestibular symptoms and showed progressive mixed losses and bilateral vestibular weakness. They were treated with cochlear implant, digital amplification and with vestibular rehabilitation. Significant others around them were involved in their journey with the medical team, and in both, a very favourable outcome was achieved. This is the first time that we have reported evolving audiovestibular function with vestibular quantification in X-linked gusher disorder and emphasize on the multidisciplinary holistic approach to manage these children effectively.

Suspension Microesophagoscopy: A Simple Diagnostic And Therapeutic Technique For Foreign Body In Esophagus

Background

Foreign body ingestion involving the paediatric age group is a common emergency referral encountered by Otorhinolaryngologists. The cervical oesophagus has been noted as the most prevalent site of impaction. Traditionally, a rigid oesophagoscopy would be required for examination under anaesthesia and removal of the foreign body is found, but this method may miss foreign bodies that are embedded into the mucosa, and faulty technique may result in perforation of the esophagus. Method and results: We present a suspension microesophagoscopy technique using a Lindholm laryngoscope and suspension to retract and suspend the opening of the oesophagus. Conclusion: This technique not only gives the surgeon an advantage to perform a two-handed procedure but also allows for a magnified examination of the oesophageal mucosa with the help of a rigid telescope for a thorough examination.

Bullet Point summary

The best diagnostic and therapeutic method for the management of foreign body in the oesophagus is examination under anaesthesia.Suspension microesophagoscopy can be done in the operation theatre with pre-existing instrument.This technique allows freedom for a two-handed technique.This technique gives a magnified visualisation of the mucosa revealing any embedded foreign body.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03383-9.

Vestibular migraine: a manifestation of long COVID syndrome in children

Long COVID-19 syndrome has been reported among children and adolescents following COVID-19 recovery. Among them, notable symptoms include myalgia, insomnia, loss of smell and headache. Yet, novel manifestations are being discovered daily. Herein, we report two cases of vestibular migraine post-COVID-19 involving two children who presented with vestibular migraine symptoms following COVID-19 infection and their management. Children post-COVID-19 should be thoroughly evaluated for vestibular migraine symptoms so they can be managed promptly. This is the first article to report vestibular migraine as a manifestation of long COVID-19 syndrome.

Topical gentamicin-induced acute vestibulopathy: A case report

Evidence suggests that otologic injury from ototopical aminoglycoside preparations is infrequent when used to treat ear infections with an intact tympanic membrane. Meanwhile, parenteral administration of aminoglycosides, is well known to be associated with a significant incidence of cochlear and vestibular damage. The discrepancy between topical and parenteral ototoxic effects is thought to result from a combination of factors, including the protective function of debris overlying the round window membrane, low antibiotic concentrations of topical antibiotic preparations, length of exposure and inability to detect subtle hearing or vestibular changes. Herein, we present a case of acute vestibulopathy following a 2-week course of topical gentamicin otic drops. Awareness of vestibulotoxicity following topical gentamicin therapy is prudent as vestibulopathic symptoms can be severely debilitating.

Outcome of canalith repositioning manoeuvre in benign paroxysmal positional vertigo in children and adolescents: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a debilitating condition that has been significantly described in adults. Recent data points out that BPPV occurs in children as well. Canalith repositioning manoeuvre (CRM) has shown promising results amongst adult patients with BPPV.

OBJECTIVE

We reviewed the literature to determine the outcome of CRM in children and adolescents with BPPV.

METHODS

A literature search was conducted over 1 month (March 2022). The primary outcome was defined as the resolution of positional nystagmus and symptoms, and secondary outcomes were determined by the presence of recurrence and the number of attempts of CRM.

RESULTS

Ten articles were selected based on our objective and selection criteria. A total of 242 patients were included, with a mean of 10.9 years. BPPV was diagnosed based on history and positional nystagmus in all patients (100%). CRM was performed in 97.9% of patients, whereby 80.5% recovered following a single attempt of CRM. Recurrence of symptoms was identified in 10% of patients with no reported major complications.

CONCLUSION

CRM has demonstrated promising results in children and adolescents. The quality of evidence is limited until a better-quality study involving randomised controlled studies with a larger sample size is completed.

Commonly Misdiagnosed Facial Lesion: Pilomatricoma

Pilomatricoma, also known as Pilamatrixoma or Malherbe's calcifying epithelioma, is a benign skin tumour with a bimodal age distribution between the paediatric and elderly age groups. Although it was previously thought to be rare, recent studies have revealed that it is quite common. Typically, pilomatricoma is diagnosed following histopathological examination of the lesion as it is frequently misdiagnosed with other types of skin pathology. In our case, the child presented with painless swelling of the left infraauricular region. The initial cytology and imaging were unable to provide a definite diagnosis. An excision biopsy was done, and a histopathological examination was suggestive of Pilomatricoma. Therefore, Pilomatricoma ought to be considered in the differential diagnosis of head and neck lesions in hopes of providing a better understanding on this pathological lesion.

Longitudinal study of olfactory dysfunction among COVID-19 patients in a single tertiary centre in Malaysia

Aim: The aim of the study was to outline the longitudinal outcomes of olfactory dysfunction amongst patients with coronavirus disease 2019 (COVID-19) in a single tertiary centre in Malaysia. Materials and methods: Adults patients who tested positive for COVID-19 via reverse transcription-polymerase chain reaction and were admitted to Hospital Sungai Buloh, Malaysia, were recruited in this study. The patients completed a questionnaire via telephone interview comprising the following details: age, sex, ethnicity, comorbidities, general and otorhinolaryngological symptoms, and onset and duration of olfactory and gustatory dysfunction. The patients with persistent olfactory and gustatory dysfunction at the time of the initial interview were followed up every 3 to 5 days until resolution. Results: A total 185 patients were included in this study out of 378 patients contacted. Ninety patients reported olfactory dysfunction symptoms, with 59 of them complaining of anosmia. The mean age of the participants was 39.52 years (age range: 18–66 years). More than half of the patients with olfactory dysfunction had no comorbidities (55.56%). Of the 90 patients with olfactory dysfunction, 66 patients (73.3%), including 40 males and 26 females, regained their olfactory function completely within 2 weeks. The remaining 24 patients were contacted after 4, 8, and 12 weeks. Ten patients (11.1%) were found to have recovered their sense of smell after one month, while 5 patients (5.56%) recovered within 2 months, and 1 patient (1.11%) recovered in 3 months. Conclusion: Complete recovery was noted in 73% of the patients within a period of 2 weeks, whereas persistence of symptoms was noted in 6 patients (6.67%) after 3 months.

Synchronous nasal mass: a wolf in sheep’s disguise

Aim: To highlight the possibility of synchronous benign and malignant nasal masses. Schneiderian papilloma, also known as inverted papilloma, despite being a common benign epithelial sinonasal tumour, remains a conundrum to otorhinolaryngologists due to its locally aggressive nature, tendency to recur as well as potential of malignant transformation. A synchronous nasal lesion adds on to the complexity of patient management. Case presentation: Herein, we are reporting an unusual case of synchronous lesions: sinonasal inverted papilloma and low-grade mucoepidermoid carcinoma. Initial biopsy of the sinonasal mass revealed inverted papilloma. However, histopathological examination post endoscopic medial maxillectomy revealed evidence of both inverted papilloma and low-grade mucoepidermoid carcinoma. Conclusion: We want to highlight that seemingly benign sinonasal inverted papillomas ought to be taken seriously considering the possibility of a synchronous malignant nasal mass, as in our case.

Synchronous sinonasal tumour: double trouble?

Schneiderian papilloma is a benign sinonasal tumour, which has three morphological variants: fungiform, inverted and oncocytic. Inverted papilloma, being the most prevalent variant, is three times more common among males in their fifth to seventh decade of life. On the other hand, nasopharyngeal carcinoma is a malignant tumour arising from the nasopharyngeal epithelium. Albeit rare, synchronous sinonasal tumour has been reported and remains a quandary till date, especially when it involves malignant and benign synchronous nasal mass. In this paper, we reported a case of a successfully treated synchronous sinonasal inverted papilloma with nasopharyngeal carcinoma in an elderly male. We would like to highlight the need to investigate suspicious bilateral nasal masses due to the possible coexistence of two different pathologies, as in our case.

Distraction Breathing Exercise in Managing Inducible Laryngeal Obstruction in a Female Patient

Inducible laryngeal obstruction (ILO) describes as inappropriate, episodic, reversible laryngeal closure during inspiration, occurring at the glottic and/or supraglottic level, in response to external triggers causing exertional breathing difficulties. We describe a case of a female patient with an underlying major depressive disorder who presented with sudden onset of stridor and tachypnoea, whereby the external trigger was psychogenic in origin. Bedside flexible nasopharyngolaryngoscopy (FNPLS) showed characteristic findings of paradoxical adduction of vocal cords during inspiration. Arterial blood gas analysis, routine blood tests, chest radiography, and computed tomography (CT) scan of brain, neck, and thorax excluded neurological or airway abnormality. Bedside distraction breathing exercise alleviated the stridor and tachypnoea. The patient was managed by supportive psychotherapy, speech therapy, and anti-reflux medication and was discharged well with resolution of her respiratory distress. We would like to highlight that meticulous history along with physical examinations are imperative especially amongst Otorhinolaryngologists as emergent airway management tracheostomy would have been unnecessary and cause more stress and burden to the patient as well as family members.

A case of unexpected cheek swelling

Aim of the study: The aim of this case presentation is to emphasise the importance of meticulous history-taking and physical examination, and increase the awareness of various possibilities for the diagnosis and management of patients with unilateral cheek swelling. Maxillary mucocele is a rare benign cystic lesion of paranasal sinuses. It may be associated with varying symptoms, and patients commonly present with compression symptoms during their first visit, as the maxillary sinus is adjacent to vital structures, notably the orbit and skull base. Case report: Herein, we present the case of a middle-aged man who presented with painless unilateral cheek swelling that turned out to be maxillary mucocele. Conclusions: Presentation of maxillary mucocele often mimics cancerous lesion types. Thorough assessment and proper imaging help to guide otorhinolaryngologists towards making an accurate diagnosis and initiating prompt management.

Cervical metastasis masquerading as Kimura disease in a patient with nasopharyngeal carcinoma

Aim: To highlight the challenges involved in the diagnosis and management of synchronous tumours. A synchronous head and neck lesion brings the attending physician into a quandary, as there is no gold standard for managing such patients. Failure to respond to treatment should provoke physicians into considering other possible diagnoses, as often a secondary lesion may be the hidden culprit. Case report: Herein, we present a case of a synchronous cervical mass: Kimura disease and nasopharyngeal carcinoma in a 48-year-old woman. She was initially treated for Kimura disease based on fine-needle aspiration cytology evidence, and later found out to have a synchronous malignancy in the fossa of Rosenmüller. Failure of Kimura disease to respond to steroid treatment led to a repeated examination, which resulted in the diagnosis of nasopharyngeal carcinoma. The patient was treated with concurrent chemoradiotherapy. Conclusion: Kimura disease, a rare benign head and neck tumour, is treated successfully with steroids. Persistent swelling coupled with treatment failure should alert physicians to repeat patient assessment, as improper disease management leads to severe complications.

Pharmacological Management of Allergic Rhinitis: A Consensus Statement from the Malaysian Society of Allergy and Immunology

The goal of allergic rhinitis (AR) management is to achieve satisfactory symptom control to ensure good quality of life. Most patients with AR are currently treated with pharmacotherapy. However, knowledge gaps on the use of pharmacotherapy still exist among physicians, particularly in the primary care setting, despite the availability of guideline recommendations. Furthermore, it is common for physicians in the secondary care setting to express uncertainty regarding the use of new combination therapies like intranasal corticosteroid plus antihistamine combinations. Inadequate treatment leads to significant reduction of quality of life that affects daily activities at home, work, and school. With these concerns in mind, a practical consensus statement was developed to complement existing guidelines on the rational use of pharmacotherapy in both the primary and secondary care settings.

Intramuscular haemangioma in a child

Aim of the study: To outline the challenge faced in diagnosing intramuscular haemangioma of the masseter in a child. Intramuscular haemangioma is an unusual type of haemangioma and is oftentimes overlooked or misdiagnosed by health care professionals. Case report: Herein, we discuss a complex case of a 9-year-old girl referred to otorhinolaryngology department for unilateral preauricular swelling, initially treated as parotitis and finally diagnosed as intramuscular masseter haemangioma following imaging and biopsy. However, the patient had to complete several courses of antibiotics and fine needle aspiration, which was inconclusive, for almost a year prior to attaining diagnosis. Conclusion: We would like to highlight early imaging and image-guided biopsy especially in children to avoid delay in diagnosis and prompt management.

The link between airway reflux and non-acid reflux in children: a review

OBJECTIVE

Airway reflux, a member of extra-esophageal reflux, has been linked to countless respiratory pathologies amongst children. The advent of novel instrumentation has enabled the discovery of non-acid reflux which was postulated as the main culprit of airway reflux. The objective of this review is to outline the association between non-acid reflux and airway reflux in children.

METHODS

A comprehensive review of recent literature on non-acid reflux and airway reflux in children was conducted. Studies ranged from January 2010 till November 2021 were searched over a period of a month: December 2021.

RESULTS

A total of eleven studies were identified. All studies included in this review revealed a strong link between non-acid reflux and airway reflux in children. 6 of the included studies are prospective studies, 3 retrospective studies, 1 cross-section study, and type of study was not mentioned in 1 study. The most common reported respiratory manifestation of non-acid reflux in children was chronic cough (7 studies). Predominant non-acid reflux was noted in 4 studies. The total number of children in each study ranges from 21 to 150 patients. MII-pH study was carried out in all studies included as a diagnostic tool for reflux investigation.

CONCLUSION

Non-acid reflux is the culprit behind airway reflux as well as other myriads of extra-esophageal manifestations in children. Multicentre international studies with a standardized protocol could improve scientific knowledge in managing non-acid reflux in airway reflux amongst children.

Olfactory dysfunction amongst children and adolescents with laboratory confirmed coronavirus disease 2019: a systematic review

BACKGROUND

Despite the rapidly emerging reports of olfactory dysfunction amongst adult patients with coronavirus disease 2019, cases involving children and adolescents are scarcely reported. The literature was reviewed to elucidate olfactory dysfunction amongst children and adolescents with coronavirus disease 2019.

METHODS

A search of the literature published from 1 December 2019 to 30 April 2021 was conducted using four databases, based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The search was performed over one month (May 2021).

RESULTS

Only 9 articles were identified, with a total of 316 laboratory confirmed coronavirus disease 2019 positive children and adolescents, of whom 156 reported olfactory dysfunction. Four studies reported olfactory dysfunction based on subjective tests; four studies carried out objective assessment. Most studies reported on olfaction recovery.

CONCLUSION

The literature review revealed an olfactory dysfunction rate of 49 per cent amongst children and adolescents with coronavirus disease 2019. Persistence of olfactory dysfunction was reported in 7.1 per cent of the patients. Further studies involving objective measures need to be carried out in children and adolescents with coronavirus disease 2019.

Infantile parotid haemangioma: a report of three cases

Aim of this case: To highlight the presentation of rapidly enlarging parotid haemangioma in three children who were all successfully managed with oral propranolol. Case report: Parotid haemangioma in infancy, albeit rare, has been vastly reported due to it being the most common tumour of the salivary gland in infants. Despite that, the presence of a rapidly enlarging tumour in “the little ones” may be daunting, leading to countless unwarranted procedures by attending physicians. Herein, we present three cases of infantile rapidly tumefying parotid lesions which were diagnosed clinically with the support of imaging, and successfully managed by promptly initiating oral propranolol. Conclusion: Although several recent reports have been reviewed, the challenges in diagnosis and management of the condition need to be individualised.

Croup and COVID-19 in a child: a case report and literature review

Croup (laryngotracheitis) is frequently encountered in the emergency department in a young child presenting with stridor. We describe a rare case of croup secondary to SARS-CoV-2 in an 18-month-old child who presented with stridor and respiratory distress and required urgent intubation. Subsequently, the child developed multisystem inflammatory syndrome in children (MIS-C). The child was monitored in paediatric intensive care unit. We would like to highlight that COVID-19 croup in children may be an indicator for MIS-C, and close monitoring is warranted as MIS-C is a life-threatening condition. Our limited experience suggests that COVID-19 croup especially if associated with MIS-C has an underlying more severe pathology and may require prolonged treatment in comparison with the typical croup or even COVID-19 croup. It is important to recognise this clinical entity during a time when most countries are in a third wave of COVID-19 pandemic.

Recurrent stridor in an infant

Paediatric upper airway obstruction is an emergency that requires immediate intervention. Among the myriad factors that leads to upper airway obstruction in paediatric age group, bilateral vocal cord palsy is not commonly encountered in clinical practice. The underlying cause of bilateral vocal cord palsy requires thorough investigation prior to deciding on the appropriate intervention. Herein, we report a 4-month-old baby boy who presented with recurrent inspiratory stridor with bilateral vocal cord palsy secondary to Arnold Chiari II malformation. Immediate intervention to drain the hydrocephalous resulted in complete resolution of stridor without having to perform a tracheostomy. We highlight the importance of meticulous and thorough investigations especially in children, as emergent airway intervention such as tracheostomy may result in detrimental effect to speech, swallowing as well as quality of life.

Outcome of Eustachian Tube Balloon Dilation in Children: A Systematic Review

OBJECTIVE

Eustachian tube dysfunction (ETD) is a chronic entity that has been historically managed with adenoidectomy and ventilation tube insertion. Recently, balloon dilation of the eustachian tube has shown promising results in recalcitrant eustachian tube dysfunction. We reviewed the literature to determine the outcome of eustachian tube balloon dilation in children.

METHODS

A literature search was conducted for the period from 1990 to 2020 by searching several databases over a 1-month period (January 2021) according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Cochrane Handbook for Systematic Reviews for Interventions. Primary outcome was defined as the success of the intervention determined by the resolution of symptoms, and secondary outcome was determined by revisions surgery and presence of complications.

RESULTS

Only 7 articles were identified based on our objectives and selection criteria. All studies included are retrospective cohort case series (Level IV) and 1 cohort of matched controls (Level III). A total of 284 patients were included in this review, with a mean age of 7.8 years. A total of 463 balloon dilation were performed either bilaterally or unilaterally. The most common finding of ETD is middle ear effusion in 5 studies. Balloon dilation of eustachian tube was second-line treatment in 6 studies and first-line treatment in 1 study. Improvement of symptoms was identified in all studies through various assessments performed. Revision surgery was performed in 1 study with no major complications reported.

CONCLUSIONS

Balloon dilation of the eustachian tube may be considered as an alternative procedure following failed standard treatment in children. The quality of evidence is inadequate to recommend widespread use of the technique until a better-quality study has been completed. Future randomized controlled studies with a large sample size are warranted to determine the efficacy of this procedure amongst children.

Intriguing aural foreign body and algorithm of management of foreign body

Foreign body (FB) in the external auditory canal is more common among the paediatric age group compared with adult patients and it may be deposited in various ways. An accidental animate aural FB is reported to be commonly encountered in adults whereas inanimate FBs are likely to be found among adult patients with learning disability. An elderly man presented with accidental penetration of rattan tree stem into his ear while gardening. Removal of a FB from the external auditory canal requires expertise as deep penetration of a FB into the middle and inner ear may lead grave complications, especially when overzealous removal is attempted by nonear, nose and throat (ENT) personnel. This case emphasises on the importance of awareness of meticulous removal of a FB under proper visualisation so as to avoid unnecessary complications. Additionally, we propose an algorithm for proper removal of aural FB in an acute care setting.

Valsalva manoeuvre to detect isolated hyoid bone fracture

The hyoid bone fracture has traditionally been attributed to strangulation and hanging. Although rare, ensuing its vague presentation, hyoid bone fracture is oftentimes overlooked and missed, leading to delayed complications. Herein, we are reporting an overlooked hyoid bone fracture in a man who attempted suicide by strangulating himself, whereby Valsalva manoeuvre performed during bedside flexible nasopharyngolaryngoscopy revealed the fractured segment. As the patient was stable and asymptomatic, he was successfully managed conservatively. We would like to highlight the awareness of the Valsalva manoeuvre, which could elicit hyoid bone fracture as missing or overlooking the fracture may lead to devastating complications which may ensue, such as respiratory distress.

Postauricular swelling secondary to salmonella extradural abscess in a toddler: a near miss condition

Postauricular swelling is usually encountered in an emergency setting in otorhinolaryngology, resulting from complication of acute or chronic suppurative otitis media. Besides that, postauricular swelling may occur secondary to various other conditions including infectious disease, tumour, vascular malformation, granulomatous condition and even trauma. Children less than 2 years old are prone to fall and up to 10% sustain traumatic brain injury without any obvious signs of neurological deficit. We describe a rare case of a postauricular swelling in a toddler which turned out to be salmonella extradural abscess from an infected traumatic haematoma. The importance of high clinical suspicion especially in a child with a history of fall cannot be emphasised more because a missed brain abscess could lead to potentially life-threatening problems. We would like to highlight that meticulous history taking along with prompt assessment and intervention is prudent for a better prognosis and recovery.

A Throat that Clicks

INTRODUCTION

Clicking larynx syndrome is a rare condition that may be intriguing to the attending clinician. Patients typically present with clicking sensations in the neck, often obvious during head movement or swallowing. Due to the scarce presentation of such cases, clicking larynx syndrome harbors a high propensity to be an overlooked diagnosis, resulting in a clinical stalemate.

CASE REPORT

Herein, we present a case of clicking larynx in a young girl followed by an overview of the latest literature on the aetiology and treatment options. This case aims to reinforce the presence of this entity further and subsequently increase its awareness among clinicians.

CONCLUSION

Expeditious diagnosis is imperative not just for the eventual treatment but also for timely relief to the anxious patients who would have been perplexed by the strange clicking in the throat.

Cholesterol granuloma of the maxillary sinus: a forgotten entity

Aim of the study: Cholesterol granuloma is a histological entity which consists of granulation tissue in which a large quantity of cholesterol crystals provoke foreign body giant cell formation. Cholesterol granulomas are often found in the middle ear with rare presentation in the paranasal sinus. We would like to highlight the diagnostic challenges and the management of maxillary sinus cholesterol granuloma in a young woman presenting as a unilateral nasal mass. Case study: We report a young woman with cholesterol granuloma of maxillary sinus who initially presented with unilateral nasal obstruction. Rigid nasoendoscopy and imaging were suggestive of an antrochoanal polyp. Ipsilateral functional endoscopic sinus surgery was done successfully. Conclusion: Albeit rare, cholesterol granuloma ought to be considered a differential diagnosis in a sinonasal tumour. This case report highlights the rare presentation of maxillary sinus cholesterol granuloma which ought to be considered a differential diagnosis of a unilateral nasal mass.

Dual retrotympanic aural mass

High-riding jugular bulb (HRJB), although rare, may pose a challenge as it may be mistaken for other non-alarming condition, such as middle ear effusion. Patients with HRJB classically present with pulsatile tinnitus. We report a unique case of a 26-year-old patient with underlying beta thalassaemia who presented with a 2-month history of intermittent epistaxis and rhinorrhoea. Otoscopic examinations revealed a pulsatile bluish mass behind the right tympanic membrane and a dull left tympanic membrane. Imaging performed revealed a finding of dual retrotympanic pathology, which consisted of a right dehiscent HRJB and left cholesterol granuloma. We highlight a rare case of dual retrotympanic mass as well as its management.

Simultaneous bilateral peritonsillar abscess in an adolescent

Aim of the study: The aim of this case report is to emphasise the importance of meticulous history-taking and examination, and to raise the awareness of various possibilities of diagnosis and management. Unilateral peritonsillar abscess is a common complication of acute bacterial tonsillitis. However, bilateral peritonsillar abscess is considered rare, and only a meagre number of cases has been reported to date in the English medical literature. The challenging part involved in the diagnosis of bilateral peritonsillar abscess is the absence of common physical findings of unilateral peritonsillar abscess. Case report: We present a case of a teenage girl who presented with a history of worsening sore throat, odynophagia and muffled voice, which turned out to be bilateral peritonsillar abscess. Oropharyngeal examination revealed bilateral peritonsillar fullness, and pus was aspirated bilaterally. The patient underwent bilateral peritonsillar incision and drainage, and was discharged well after a few days, with no recurrence. Bilateral peritonsillar abscess can present with usual symptoms, but physical findings may vary. Conclusion: Proper history-taking and meticulous physical examination may direct the physician towards correct diagnosis, and an imaging evaluation is warranted if in doubt, so as to avoid unwanted perilous complications.

Aural polyp with facial asymmetry in an unfortunate infant

Temporal bone rhabdomyosarcoma is an aggressive entity that simulates chronic otitis ear infection. It is the most common soft tissue sarcoma amongst pediatric patients. Herein, we would like to report a case of temporal bone rhabdomyosarcoma involving a 2-year-old boy who presented with a one-month history of otorrhea with facial asymmetry. Early treatment led to remission of this severe neoplasm.